Optimizing Care Transitions: Where Do Predictive Analytics Tools Fit In?

That’s the intent. But we might run into the same issues, if a patient is being discharged to a provider that’s not a part of that ACO. And the sad part is, there’s a ton of technology, and there are CCDs [continuity of care documents] and everything else; and what’s really needed is so, so minimal. You don’t need to communicate the entire record, rather just that the patient was in the hospital for this reason; they have been started on two medications and taken off another med; they had an abnormal stress test, and their last hemoglobin was 10, and you need to recheck that over the next week. And that’s a simple set of pieces of information that often gets lost in the wash of data.

So what do clinicians, care managers, and clinical informaticists need to do in this whole area in the next couple of years, to improve care quality around transitions?

I think that data capture and collection and access to information have been the bottleneck. Physicians are often overwhelmed having to collect everything. And they’re overwhelmed having to track lab results back and forth. So accessing and collecting information needs to be done for us physicians. Most quality folks spend 95 percentthe majority of their time collecting data and entering into charts and tables of some kind; but very little time analyzing data and thinking about it is actually being done. Hopefully, we will be freed from the information collection burden, and the quality folks will actually be able to work on quality, and the physicians will actually, hopefully be able to spend more time talking with patients, now that this administration task has been taken off of us.

In addition, I believe that tracking and following data will increasingly be pursued by [specialized care management professionals]. And once those tasks come off us doctors, and we’re able to spend more time on patient care, important conversations will take place among all these [stakeholder] groups.  I already see that happening here at Inova. And I wasn’t even looking for quality folks necessarily to join this team, but people are coming to the team because they’re interested in leveraging the data for quality improvement. So I’m hoping that hospital organizations will be able to change their structures to reflect not just multidisciplinary teams on rounds, but also in hospital operations.